Cover Essay: Reviews in Spinal Surgery: The Quest for Balance

“Life is like riding a bicycle. To keep your balance, you must keep moving.”

—Albert Einstein

Spinal surgery has witnessed a number of critical evolutionary gains over the last 40 years. At one time, the diagnosis of spinal disorders relied solely on plain radiographs and myelography, and surgical treatment options were largely limited to laminectomy and posterolateral uninstrumented arthrodesis. Although those procedures and techniques still have their place in modern-day practice, the spinal surgical “menu” has expanded enormously. Novel techniques have emerged, often hand-in-hand with novel devices and advanced diagnostic as well as intraoperative imaging. The contemporaneous advent of widely available magnetic resonance imaging along with pedicle screw instrumentation in the 1990s led to a greater appreciation of the utility of spinal stabilization procedures as our ability to diagnose and treat spinal instability improved. Similarly, multidisciplinary advances such as stereotactic radiotherapy have radically changed the way we surgically manage specific disease types such as metastatic spine disease. Minimally invasive spinal surgery has reduced perioperative morbidity and length of stay such that many common spinal procedures may now be performed in an ambulatory setting. New biologic agents as well as unique implants such as total disc arthroplasty have in some cases supplanted more traditional materials. Multicenter study groups and prospectively collected patient reported outcomes measures (often through formal clinical registries) have vastly improved our understanding of the quality and the value of the techniques and devices we utilize. Collaborative research, for example, greatly advanced spine surgeons’ appreciation for global spinal “balance” and how derangements in the alignment of one region of the spine or in lumbopelvic parameters can contribute not only to changes in important global radiographic parameters but more importantly to patients’ pain and disability.